Castro’s legacy. Cuba’s achievements in health have been remarkable.

Nov 30, 2016

In the article from The Lancet, Arjun Suri points out that despite spending one tenth per capita of what the US spends on health, Cuba’s infant mortality rate is better than the US and that the two countries have equivalent life expectancy.

I think it is fairly clear that the Cuban success derives from two main features. The first is that Cuban Health Care is based in the community and not in hospitals and is focussed on prevention. The second is that Cuba has been spared the devastation of private health insurance which makes US healthcare the most expensive in the world with extremely poor health outcomes. 

See article below by Arjun Suri in The Lancet which was published on February 13, 2016.

John Menadue.

Midway through my third year of medical school, I had a class session to discuss the changes that would result from the US health-care reform bill. The lecture was part of our school’s attempt to educate us on the policies that would aff ect our careers. The session had only just begun when a classmate remarked, “I just want to know how much I’m going to get paid.” Laughter swept through the room, leaving only a few people looking surprised. Soon after, another classmate, a self-proclaimed future orthopaedic surgeon, raised his hand and asked, “Why are we paying primary care doctors more?” He went on to argue with one of the speakers, an up-and-coming primary care doctor, and insisted that the latter’s job would soon be replaced by nurse practitioners.

The concerns of my fellow students at Harvard Medical School came back to me when I spent some time in Cuba to study its health-care system. One afternoon in Havana, I was talking to two neurosurgeons about the state of wages. One of them was Cuban and the other a Nigerian who had completed medical school and residency in Cuba. They described the frustration of not being able to own a car or a home. Cuban doctors earn roughly US$2 per day. Neurosurgeons make about $5–10 more per month than general practitioners.

To put this in context, neurosurgeons in the USA earn nearly 500 times more than their Cuban counterparts. Educated health professionals in Cuba earn the same as or less than individuals who have only a basic education—what is referred to as the “inverted pyramid”. I met doctors who worked part-time as bartenders, taxi drivers, and artists to supplement their salaries as physicians. Undoubtedly, Cuba’s health-care system functions on the backs of its health professionals. Despite such vast financial disparities, however, the neurosurgeons who I talked to seem to have chosen a specialty they loved for no other reason than that.

During my time in Cuba, I was struck by the way that doctors belong to the same social class as the rest of society. Most family doctors live in the communities they serve—often, on the floor above their clinics—and are available at any hour for emergency consultation. I have repeatedly asked my Cuban colleagues what drives them to pursue careers in medicine; the answer is always something along the lines that it is a calling. Financial incentives do not seem to drive decisions to enter medicine or choose a particular specialty. These observations in Cuba have also led me to ask how much weight do we place on financial incentives to drive both patient and physician behaviour in the USA? How does the curiosity and desire to help others—so evident in every medical student’s personal statement—so often get replaced in just a few years by a narrower vision of career progression and personal financial gain?

In Cuba, it seemed to me that the social value of medicine was nurtured during medical education. Social medicine seeks to understand how social and economic factors influence the health of society. In most American medical schools, we are taught the bio-psychosocial model, which seeks to incorporate multidisciplinary aspects of health. Although useful in framing a patient’s disease in a broader context, there is a social orientation to the practice of medicine evident in Cuba that is largely missing in the US health-care system. While students at my medical school head to business school in droves (the MBA seems to be the currency of power for those who want to shape American health care today), medical students in Cuba spend one day of every week during the 6 years of medical school dedicated to health promotion, or pesquisa. Students go door-to-door in the community, primarily seeking out cases of fever or diarrhoea as part of dengue and cholera prevention, as well as educating families on how to prevent such diseases and when to seek care. Their education also exposes them to a range of community-based work, including agricultural harvests, pest fumigation, and sanitation clean-ups. As WHO Director-General Margaret Chan said when speaking to a class of graduates of the Latin American School of Medicine (Escuela Latinoamericana de Medicina, or ELAM):

“You are being trained to return the practice of medicine to the basic values of people-centred, compassionate care, guided by need, and not by the patient’s ability to pay…to spot community-wide threats to health linked to living or working conditions, or lifestyles and behaviours, or what people eat, drink, or think…to be engaged members of the communities you serve, and not just doctors in white jackets waiting for the problems to show up, preferably by appointment, in your offices.”

Although a mere 90 miles separate Cuba and the USA, there are, of course, profound
differences between the Cuban and US health systems. Cuba achieves better infant mortality rates and an equivalent life expectancy to the USA while its annual health-care spending per person is less than a tenth of that in the USA. Yet there are also limitations to practising medicine in Cuba. The economic blockade by the USA profoundly limited Cuba’s access to essential medicines and basic equipment. Cuba is rich in human resources, boasting one of the highest doctor-patient ratios in the world, but it struggles to find the equipment necessary to provide comprehensive medical care. For example, CT scans are not readily accessible in most hospitals, and it is not uncommon to sterilise and reuse surgical gloves. Faced with such problems, I noticed how inventive the physicians I met had to be—I saw the finger of a rubber glove being used as a surgical drain and lubricant being applied as glue to stick lab values into charts. It is difficult to imagine one truly thriving under such financial constraints. With the loosening of trade and travel restrictions under the Obama Administration, there is hope for greater investment in physical infrastructure in the future.

Notwithstanding its drawbacks, the Cuban health-care system has an almost militaristic level of organisation with primary care as its foundation. Family medicine, a fi eld known in Cuba as comprehensive general medicine (medicina general integral), is a core requirement during every year of medical school. Furthermore, most Cuban medical specialties require a physician to first complete a residency in family medicine. By way of contrast, my US medical school had neither a Department of Family Medicine nor offered a residency in this area. The Cuban primary care system is organised such that a family doctor is assigned to roughly 100–200 families, which comprise a consultorio. This doctor lives within the community he or she serves and visits each family at least once a year, or more often depending on the severity of illness in each family. That means that every person in the nation has access to a physician who knows how patients and their families live, eat, and socialise. …

The home visit is a valuable part of medical care that underscores Cuba’s focus on prevention, coordination, and connection to patients; it is something that has become neglected in the US approach to health-care delivery. Cuba’s health-care system promotes health with comprehensive prevention and healing through longitudinal relationships between physician and patient, woven into the fabric of the community. At the same time, as a single party state with serious limits on freedom of speech and expression, Cuba does not represent an ideal system. Yet despite the limitations of the Cuban health-care system, as a medical student who seeks to envision a health system that ties prevention to treatment and coordinates care at every level, I am humbled by the way Cuban physicians practise a form of social medicine that my fellow students and I are taught only in theory. I have found it inspiring to learn among medical students and physicians who continue to be motivated by service to their communities.

Fostering a real connection between physicians and their patients has always been central to maintaining the values of our profession. That connection is a fundamental tenet of Cuban medicine. Perhaps my American classmates would be asking different questions if this social approach to medicine formed the basis of our education and practice. As I make my way through intern year in internal medicine at San Francisco General Hospital in a programme that teaches physicians to serve socially vulnerable populations, I often return to the lessons that I have learned from my Cuban colleagues.

Arjun Suri UCSF School of Medicine, San Francisco,

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